Utilization Review Nurse
Location
United States
Posted
23 days ago
Salary
$64.2K - $96.3K / year
Seniority
Senior
Job Description
Utilization Review Nurse
Tenet Healthcare
• Collecting, analyzing, and evaluating clinical documentation received to determine appropriateness of clinical decisions • Adherence to regulatory and departmental timeframes for review of requests received • Responsible for the effective and sufficient support of all utilization management activities to include prospective/ pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies. • Using an established set of criteria evaluates, applies and authorizes the medical necessity of inpatient and outpatient services. Referring to medical director when unable to approve a request. • Manages the provision of cost containment services by determining the medical necessity and appropriateness of setting and treatment, and channeling to network providers. • Uses clinical knowledge and evidence based criteria to determine the medical necessity of an inpatient admission, treatment plan and goals, identified gaps, risk for readmission or complications and any barriers to discharge • Collaborates with case / disease management departments and vendors to support client contractual agreements, SLA’s, SPD’s to ensure member receives quality care • Supports quality assurance initiatives, quality indicators and performance standards following standard documentation and ERISA / URAC guidelines
Job Requirements
- Bachelor degree in a health related field
- Five (5) years of UM/CM experience preferred
- Three to five (3-5) years of diverse clinical experience required
- RN (Registered Nurse) license required in the state of residence
Benefits
- Medical, dental, vision, disability, life, and business travel insurance
- Paid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.
- 401k with up to 6% employer match
- 10 paid holidays per year
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
- For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.
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